"Health Care in Cuba Today" – PNHPWW June 19 Monthly Meeting

"Health Care in Cuba Today" - PNHPWW June 19 Monthly Meeting



here's my presentation today this explains this is a mural of the Cuban flag and there's lots of what they call propaganda of commander Fidel Castro and so that's speckled all over you'll see is that health clinics and all over in the park here there so I thought it would be fitting to have that there so women medic which was medical education cooperation with Cuba and there is amazing group they're based out of Oakland California and they do a lot for it was started by a journalist this woman right here in jail and and thank you a lot in terms of collaboration in terms of helping low income individuals from the United States idea you languages we'll talk about that more in the later on science have medical school only in for international students in Cuba funded by the Cuban government so many sent a lot and they actually reflected us those of us who are coming if you could bring some gifts so I had my suitcase full of surgical love tantowels and and other medical supplies and and everyone about nineteen people or 15 people who came on the trip also did the same so we were able to contribute also in addition to learning so much so the theme of our trip it was pretty amazing it was women health and leadership so medic organized this beautiful trip with all women entrepreneurs and leaders and medical directors and heads of Parliament and all kinds of things for people for us to meet and and inspiration for us and most the entire group was women except for a young man someone's son joined alone and so the the women who who came from the u.s. on this trip work for Kaiser women who are presenting to us let me start with that where the director of polyclinics professor and organic farmer molecular immunology researchers psychologist activist and student so let me tell you a little bit about what's happening in Cuba right now as of 2017 the population is a little bit more than 11 million it's about 20% 60 and above urban dwellers are a large majority and the life expectancy is about 78 years I won't go through all of this except to say that they have impressive numbers in terms of how many health science universities they have how many healthcare institution so polyclinics which we'll also talk about are the backbone of their health system and they have many of those they have full immunization coverage will also discuss that so just to give you a not like some more background information about women – that was the sort of topic of our trip there half the population say a little bit better life expectancy and how the behavior and they have pretty good education at least mostly half have finished high school we also talked a lot about the social landscape of women and gender as well on the stress of forty five percent are in the paid labor force and just to give you an idea before the revolution in 1959 about 13% were part of the workforce so it increased quite a bit and I just thrown in some to show your maternal health it was one of the most incredible achievements that Cuba's Health System has they've being not a high-income country they've already achieved I am Development Goals many even though they expired in 2015 many countries are not there yet but Cuba is and they have a lot of agreements in place with women and environmental rights in 2015 he was became the first nation to eliminate altogether HIV transmission from mother to child that's a huge achievement and we're not anywhere near that yet Cuba is one of the stages of countries to become a mother because of all of the infrastructure that they have in place for taking care of expecting mothers and they have a great doctor to patient ratio is the highest the highest in the world 127 people per Doctrine and 61 percent of the physicians are women and and so they have a lot of a lot of work to do but they make many accomplishments in terms of gender as well so this is just another propaganda or there's no advertisements there you can imagine so these are the only kind of billboards and science and things and this means you know strength in our unity and who our first day there we got to hear from this professor who was teaching for over 40 years at the University of Havana she's an amazing professor she she's a consultant on gender for several UN agencies and has done an amazing work and one of the really cool things that she did was she was able to interview different pop pop musicians and and talk to them how they Percy of machismo which is the term of masculinity or toxic masculinity and and interview them ask them what do you think of this and how do you how can we change this in society and they they were all aware this but told her later on that they had to sell what they had to sell so they couldn't they couldn't change their music so in terms of my teas multiple culture if if there is humor if you've ever been to Latin America that's that's part of the culture and so a lot of women were talking about that we met were talking about she sees the perception and this second shift so part of that culture is that women many of the women about 60% of the women have professional Java but they're not able to come home and relax they also have to do the cooking and cleaning even if their partners unemployed because of the culture so talking one of the big thing to us they were talking about changing that second chip so on the second day we were able to go to a poly a clinic and I was a leave there in queue about one a week so I hope that this is an invitation to research more about the health system because forgive me if I get something wrong here but it was a quite complicated but it's very amazing so we went to this clinic called the 19th of April and if any one other significance of that date yes for them it was the Bay of Pigs victory so this is the 19th of April clinic and I've put that map there because one of the most incredible things about the public health or about the health system in Cuba is that public health is sort of woven into everything that they do all the doctors all health providers learn about public health and practices so one amazing thing that they do is that they mask everything so this polyclinic the area that you see in the mask is actually in the area of the polyclinic so it's not the physical building but if that buildings and everywhere it's in the map and so in that catchment area is where the where all the patients come from and just to give you an idea of of that population there it is about 25 or 26 thousand people and let me see some of the data here 17.9% are are 14 years or less and they collect a lot of data and it's really incredible that they use this data to implement the work that they do at a clinical level so they have this treatment this sort of paradigm of treatment with these for health promotion prevention treatment and rehabilitation and so they use that to plan up to one year ahead and they have like the minimum treatment so far for a mother's expecting there'll be a minimum of 16 prenatal visits and and so they use this data to plan their their cares for the whole year and so the people is in phase 3 which would be the treatment or 4 which is the rehabilitation work get more visits and people in the health promotion phase would get less and so they use and then the we have specialties and so it's focus their health system is largely focused on primary care and all these specialties are are part of the team which are headed by the family doctor and nurse so the principles of the Nationals Nationals a salute SNF is it's based on both rural and urban health which is what they're right here it's based on it's not based on your political affiliation or any sex or race it's not based on religion it's just whether you're a human citizen or not and they they also work towards the treatment and care of the international community as well and that's embedded in their health system and there's of course in the presentations that we went to at the following clinic there's mr. Fidel Castro and the quote from him she's all over the place so the structure of the National Health System is as I've said before it's a little bit complicated but what was really amazing about it is that this base sort of the bedrock of that system is the primary care and that's all B's and the red box is the polyclinic system so that area this huddle is polyclinic catchment area and the grupo bicycle is the set team of primary care and specialists so they'll have a dentist and so this is the sort of outlining the group and cosa dentist a pediatrician gynecology internal medicine and so they have that team of specialists which is sort of up here and they're working with a couple the primary care team and who and and all of these data and all of the information is collected at a national level and and managed at this kind of higher level and very structured more of the values of the health system are our focus paying on the social determinants and in my other PowerPoint I had the picture on the right on the right type the software that they're starting to use now that tracks the social determinants of health of patients within the following clinic area and when they've only been doing this for a few years I think they started it in 2016 but I was really excited about that and some of the things that they found out or that patients weren't getting access to transportation and on this slide I also had a picture of an electric bus it's vanished but they have some in Havana they have like all electric buses as well so they're trying to work with those data and and bring more transportation towards hospitals and clinics and and really taking into account social determinants which you all probably know better than me whether that's incorporated in the health system here or not but I was really impressed by how how much they consider that and that they're analyzing those data at a pump at the level of the polyclinic and even at a national level so again another huge achievement and amazing program that they have is for maternal and child health and they've achieved zero infant mortality and zero maternal mortality as you can see here that's not the case heat in the United States but we can see that one of the establishments that helps them with those that achievement is this kind of this kind of place which is it's called Oh God but they're not in funding and it's for expecting mothers to go and live if they're living in a difficult situation like a situation of domestic violence or poverty or anything difficult during their pregnancy they can go stay there there's health providers who'll take care of them and sort of monitor how they're doing once they go and give birth they can't stay there anymore but that that kind of a place is a residential place where they can stay and receive care and it's of course all of this is funded by this the federal level so other strategies that they've done and things that they've tried here are a new treatment for diabetes and they're reducing the level of mmm mutations by sort of taking a more preventive approach and because as you can imagine when the government is paying for all the heartache and it's very expensive to do extra surgeries and extra procedures that don't need to be done or that can be prevented so at the level both of quality of life for the patient but also for major cost saving there they're doing a lot of innovative research – for prevention and they also are a hundred percent covered by vaccines and and they have a number of infectious diseases that they're still dealing with such as tuberculosis viral hepatitis meningitis and leftover OSes which are pretty well covered by the prevention that they have as far as women representation in policymaking Cuba is among three countries with 50% representation in Parliament and it's one of the highest percentages of women in Parliament in the world and so there's a map of Cuba it kind of looks like a as they said a lizard and so the the next day the the third day of the trip we went to a women's cooperative so we met a woman named Eloise and she started this beautiful farming collective choose a teacher and because of that mighty small culture that we touched on in the beginning she pitched this idea to her husband about starting a farm to address some of the food security in a more rural area and artemisia province and he said no like how will you do the housework if you're doing a farm and she was like okay well I rather do the farm and and I think it was a really difficult because she and the other woman who are presenting about starting this farming cooperative were both really pained by that relationship and that circumstance but they were also had a lot of conviction to do this to increase food security in that area and grow medical plants and so they have this beautiful farm and so here are some of the pictures of the farm that's cashew the the pink fruit over there and hanging down from there is the kind and this was the restroom at the farm this is an orchid they have beautiful orchids of the farm and so she and her son actually worked very hard and started this farm and now they have other workers but it was really a huge endeavor and the other women who presented with her started a Cultural Center and they're sort of reviving the culture of runaway slaves and bringing back that food and the traditions of of runaway slaves and they gave us some coconut bread to try and it was unbelievable it was really good and so we got to see how women sort of fight some of these societal barriers but still have that conviction to do it and and it was pretty amazing we also saw some of the process of making coffee and they took us on a tour medic organized a tour of the place where it was done traditionally where they dry the coffee and the bottle khones is where the slave um bearings were and so it's actually beyond that wall so you can't see it very well and so all those and that the one on the side is where they they put coffee beans all around here and this huge wheel presses the coffee and crushes it and endi shells it the fourth day we went to the Center for molecular immunology and this is a very high-tech place it's very amazing they had a floor plan that I thought was really a beautiful sight at that picture and and so this is head by women and many of the students are women and they're me projects that they're doing it's cancer research and antibody production and whatever kind of medical products that they make there they're selling them to generate revenue so this CI M is actually most of the establishments that we've looked at so far our government-owned but in the last ten years they've opened up the economy to self-employment so this is this institute is half enterprise and half government-owned and they generate revenue with some of the products biomedical products that they make but anyway I can talk about this one um it was a Center for activism and women's rights so this is the woman that you see there is a psychologist and she has a number of social projects because there isn't actually even though there's a lot of federal programs there is not a an official program for domestic violence and protecting women in that sense so this is a center that does a lot of social communication and culture change work and they're very amazing organization and they make all kind of networks with youth and with men and what sort of cultural change elements and so so that was really eye-opening to see the kind of banners and campaigns that they put everywhere they put them on buses they worked with Oxfam and made a movie because one of the things I even experienced in Cuba was there's a lot of like very forward men who just come forward and which is part of the machismo culture and they just say hey like catcalling kind of thing we also definitely have that here and and so one thing that they did that that organization was make a video where it was actually kind of funny where women were doing the cat Kali just as a social experiment and the men came and said oh that's so strange like to see women acting like that I feel sorry for them like why are they doing that and it was just kind of interesting to see that social experiment and other kind of social experiments that they that that organization does so those really eye-opening one of the really incredible things that we got to do was we got to talk to a lot of health providers so our last day of the trip day five was talking to women who are doctors nurses IT professionals speech pathologists statisticians who have gone abroad and helped out with just done their own job but done it abroad and and they see this as as a duty so if you remember from one of the earlier slides part of the National Health System included international work so they see it as a big as a part of their own job so we got to talk to them and and ask them questions and and they said that even many of them have families their parents and they go because they they feel that this is a duty and I was really touched by that and I had a lot of numbers on the presentation about how many providers are in different countries but but the people who we we spoke to had been to Mozambique Venezuela Guatemala Zimbabwe all kinds of places and it was very amazing to hear their stories because very often Cuban doctors and health professionals go to the places where local health professionals will not go and they told us all about that and one physician told the story about how she was working with a nurse and I don't remember which country it was in but it was a rural area and it was a place where the part of the custom there is to have a lot of children maybe like nine children on average so that was normal so the woman that they that that was telling us about this was a primary care physician but she had across a crash course in surgery before she went to Africa and she was working with the nurse and she had to do caesarean section on the woman who was who was pregnant and due to a complication which maybe David would know what that is they had to take out the uterus of the mother and she was bleeding so much that the doctor and the nurse and like they just got the gynecology on the phone and they were like taking the consultation and doing this procedure just we have phone instructions and then they actually ended up giving their own blood because they had no blood supply and no other basic supplies there so so they've gone through a lot of very difficult circumstances to do this work but they keep going because they see it as part of their work which is I thought that was an amazing ethic that they have and sort of perspective on the global health care so and there were all kinds of amazing stories that was just one of them and so these were some of the people and and so part of the reason that they go though is that their national health system I'm sorry their national health system takes care of them to do that so that was one of the incredible things that they told us about was that that the Ministry of Public Health takes care of them make sure they get to vacation make sure they come home and see their family and and provides that as if they're just doing a job because they don't really go as an organization very often if if us has health providers or as American professionals go we'll go with an organization like doctor without borders or save the children or BOGO with someone but they just what Cuban health professionals do is that they slide into the health system of that country or place that they're going and they do their work as part of the health system of the place which is also unique so we also on the same day we got to hear stories from the students of Elam which is the Latin American medical school again I'm not sure if I mentioned it already but those are it's a only for international students paid for by the Cuban government and it's a really amazing place where people from all over the world so there were students from Angola from Colombia from Los Angeles there's one student who had gone to Evergreen State College and then came to Elam so I was excited to meet her and and the one wearing the pink came from Chad so they came from all over the world and they so what they do in alum has they start to learn Spanish when they come and then they start taking the medical classes and then when they do begin their clinical education they integrate with the Cuban medical students and so it's a really incredible place where people from all over the world who never would have had an opportunity are able to come and and one of the videos that I wanted to play for you was one of these students I don't think she's in this picture the one from Angola her she had been treated by Cuban doctors as a kid so she when she grew up she said oh I would like to go to Cuba for medical school because those doctors were amazing so that was her story of how she got there so it was wonderful to hear about that and and the opportunities that Cuba provides locally when they go to other countries and fill the voids in health care but also what they provide in terms of making other countries for countries more like fortifying the health system in that way as well by by helping them get health professionals because one of the stories that they were saying were that they wanted to go to medical school in their own country but sometimes the professors wouldn't show up they wouldn't have class for two months and and they couldn't really get an education in that way it was very difficult so going to Cuba meant a real opportunity so I just put these on here these are some paintings and this is a kind of landscape there's mountains so I will open it up for questions now experienced well that's actually a good question we didn't get to talk to patients in the clinics and in the hospitals but we myself and some of the people on the trip were able to go just walk around Cuba and meet people and talk to taxi drivers and and most of the people were pretty pleased with their health care and satisfied with it and grateful for for free health care and free education and I can't think of any complaints right now but I'll keep thinking about that the students that we spoke to had mostly were all from other countries so those the people from those countries were definitely even the ones from America because there was a student from New Jersey from Los Angeles from Maryland and and I think the comparisons that I I was able to hear about Werth favorable towards the Cuban health system especially in terms of being able to go when you need care like not being afraid to often because you'll be worried about how much it'll cost so you know here in the United States is as a lot of discrepancy in the remuneration the salaries of physicians that the primary care people make much less than for example the interventional radiologist and biologist so did you manage to get some information on what what typical discrepancies might exist between specialties or are they was pretty much fun with genius in terms of their so what the doctors earned there is about 60 CU c firm per month so so that's very little and the compensation for everybody is very little the people who actually make the most money are people like taxi drivers and people who get tips and people who work with tourists because they they get tips and in dollars and they get a lot of extra of supplemental income and people who are doctors and nurses and and professions that are highly paid here do it for the personal and professional satisfaction of it and so the the director of the polyclinic who who gave us to talk about the whole health system she was saying that she lives comfortably because her husband is a cook mentioned that they developed a new treatment for diabetes or they were developing one they had a lot of innovations that i didn't even put on this slide show they had a treatment of six to eight week topical treatment for diabetes for ulcers for foot ulcers they were telling us about a vaccine for lung cancer not to prevent lung cancer but to prevent symptoms in third and fourth stage to improve breathing and improve quality of life they were telling us about a nasal spray that they're developing to alleviate or sort of work on the progression of Alzheimer's and Parkinson's and so that's a new thing that they're so they're developing many interesting things that are definitely for patients quality of life but I can see it as a huge cost saver as well because so many of these diseases are very expensive when they progress do they make them insulin in within to burn are they important from someplace you probably heard what's been happening in some prices here it's a good question I think we did cover that and I don't remember I can try to find that out and send it to David yes this has to do it even in the mother and infant the home that they can go to especially if the conditions for maternal health and child health are not good conditions then what happens after birth you said they have to leave that facility where do they then go to back to their squalid living they do go back home and we didn't get to learn as much about next steps of that program but in I don't know if it was evident with all of the diagrams the pictures of the slides that I showed but in each of those primary care teams there's also a social worker so that might be part of the safety net of dealing with people who have difficult circumstances you mentioned that they cover all citizens now do you have any refugees there or for example a file or tourist and I went that got sick would they take care of me no charge as far as I know yes because we were told when we were going with medic that we didn't need to get insurance to go there or anything like that so so as far as I I know I think it's covered so you had mentioned that some of the research was partly individual Iran or I guess I wouldn't say profit us but did you run into any other facets of the health system that are moving towards a privatized health care system so like for for an extra care for example so we know that in Brazil plastic surgery is actually part of the government program as part of the single-payer system but in Cuba did you see anything that was like more private dinosaurs oh that's a good question um well I mean so the privatization is is happening but it's going very slowly and it's called self-employment and what I saw of that is that it was see IM was 50 percent so that was the most privatised thing that we got to know about in terms of extra procedures I don't know that there's enough resources to do anything extra um because we were bringing medical supplies and I know that most medical establishments especially with the crisis in Venezuela and and during the special period in the night when resources were really low and there still there's still not a lot of surplus of resources I don't know how much but that's a really good question what kind of what is the protocol for extra people could travel to the US and to Cuba better at the end of Obama's term and then when Trump took over he changed that in some way and I was wondering if you knew how his travel out of Cuba and to Cuba handled now in the u.s. the way that we were able to go was through people-to-people exchange and I believe that's what was repealed while we were there so we were lucky enough to be there but before they stopped it had they done it a few days earlier we would never have made it to Cuba but some of the ways of exchange still do exist I believe academic exchange still exists and certain maybe one other visa you can get but but I think he's trying to eliminate most of the other ways you can travel there well there was a policy of immigration for Cubans that once you reach the shore you're safe I don't know if you know about that that's the old way so they they stopped that and then I think that the current tightening of immigration that's happening also applies to Cuba I'm in the same way but I might I'm not the expert on that so these are some of public health kind of advertisements or propaganda is a comment that our president in like in the clinics in the doctor nurse in the buildings so one thing that I didn't get to show you is oh I didn't get to show you this slide because it was missing but this slide talks about some of the demographic issues that are current in Cuba right now there's there is a housing crisis migration out of Cuba is a big thing there's lack of both hardware and even things like machines and washing machines and car parts and that kind of things but there's also a shortage of technology and people said that that was the limitation there there's a big a large percentage of the population that believes in afro-cuban spirituality and religion and the professor who spoke to us said that she actually opened her talk by saying that she thinks that freaking diaspora for the open society that they have which was really impressive to me because I've never heard someone in the u.s. thanking our African diaspora for the great things in our culture but but she was saying that there's no opposition to abortion and vaccinations and some of the things that were struggling with here because of that culture and she also wrote that they're very pragmatic and so like gender roles are a little bit more flexible because of that society and she also talked about how they have more of a culture of Syria monogamy rather than marriage and part of the empowerment that started with the revolution in 1959 was the women's empowerment and I have it on one of these slides but one of the loves that came into effect was equal work equal pay from between men and women which we don't have here and and things like that which gave women a lot of power and actually you someone had asked a question did you ever get to talk to patients so when we talk to people on the street about I actually had a lot of time asking like the pregnant that we met about machismo so I would ask them like do you think it's more in the United States or in Cuba and they were like definitely United States Cuban women have all the power so I thought those interesting that they feel that way even if there's more progress to be made another interesting thing is they're on the 8th of this covered it up but they're on the 8th version of their constitution so they keep changing as we keep amending and I thought that was very amazing that they do that let me find some of the other pictures oh another thing that my one of the things I I was most impressed by is that they keep record of epidemiologic surveys um during the medical visits so when the doctors and nurses see their patients they also have an epidemiologic survey that they fill out during that visit and as someone I taught an epidemiology course this quarter and and all of my students are health providers they're all respiratory therapist and medicine and they all have experience of patients and none of them had had heard of epidemiology beyond maybe the word but they didn't know what it was about so it was amazing to me that this is very integrated into their health system oh this is the software that I was really excited about that the that they use at the level of the polyclinic to measure how the social determinants of health and that's the electric bus and what else do we miss here Oh so this slide oh it's completely missing this one was the family nurse doctor team and so this is an apartment building where people live and so the doctor this the doctor this the nurse and they lived in that building and it's a little stressful our uncle how they're well they're there but they definitely do get days off and everything but but they have medical charts both for the patients but also at the level of the family so that's another way that they can assess risk of patients is by having a chart for the whole family more pictures oh this is the capital that I was raving about earlier it's a beautiful building this was when we went to Parliament and there's woman is front of the Parliament and these other two are from the Cuban Federation of women and that's a big volunteer-based organization that does a lot of the community health work with rural populations and stuff like that so they do anti vector programs and and screening and you and so this volunteer organization the Cuban Federation of women does much of that work and so so these are some of the pictures that were missing and I think I'll leave it up to questions again cuz some I think we're almost time so like just about everywhere else to deal with this obesity epidemic is there data on that problem so they have diabetes that's actually a great question what I saw in some of the data that they were presenting is that under nutrition is much more of a problem so diabetes it's probably maybe alcohol related this is significant and mental health generally what any data on prevalence so using innovative in dealing with mental health is one thing that's amazing is that most of the providers are trained in some type of natural medicine and stuff like that so they use I think there's a lot of because of the African Diaspora culture there's a lot of mental health that's not called mental health which is ceremony and they regularly people talk about taking out the bad energy and bad spirits and and so I think in none during terms there's a lot of cultural work around mental health I didn't see a lot about it in the health system but what I did someone asked a question about the opioid epidemic and asked if its present in Cuba as well since it's so big here and one of the professor's was telling us that that there is no way to get opioids in Cuba like they're not there is not very many there but what happens is when the packets are sent from South America to North America sometimes they excessive I see and they actually wash up on the Cuban shore so and these are huge pockets so people who get a hold of those starting I mean they might sell them and use them and things like that so they have been seeing that because of the sort of by way of sea but in terms of the actual mental health and psychiatry I didn't hear a lot in the trip Alabama policies yes there's a housing crisis which one of the professor's mentioned but but there's also intergenerational family living so it's very normal for people to live with grandparents children is that so home of housing is a problem but there's more mechanism dealing with that because of the culture but there is there is homelessness when I was there there were clinics for natural medicine just focusing on that kind of sand alone do they still have that sort of thing we didn't get to see it but I believe there are because when we were at the farming cooperative there was they were growing all natural medicines and they were supplying it to medical providers but but there must must definitely be you actually saw a clinic I saw pharmacies there were natural natural there are pharmacies that dealt with natural but the farm the farm the doctors would would prescribe these natural medicines from the natural part as well I saw one focused on natural training one thing that impressed me most of all I was there us in a small community clinic you mentioned they have the records of the family all together and the people of providers in those clinics know the family you know each person in that family and if somebody doesn't show up for an appointment they will send the nurse out to go see a presentation I was a patient too sick to come to the clinic a member of society by clinic and their appointment they made there was definitely sort of the care that they got at the clinic but as as shown on that slide with the map the polyclinic is the whole area including that the housing in the residential area and everything and that's the polyclinic area so they don't count it as a physical building but as those people's homes they'll go there they'll find the patient so they told us all about that and I was I was also really impressed by that and so Brazil it's in a crisis right now because Cuban doctors were serving I guess more than 28 million people and the current administration there had a problem with Cuba and a diplomatic issue and and kicked them out so 2,000 of them actually tried to stake that article that I read is in the Miami Herald so 2,000 Cuban doctors and professionals tried to stay in Brazil but but they're having a really hard time like all over the world in in the 2013 to 2015 a bola epidemic Cuban doctors were on the front line and health professionals there what it says in this article which is a few years old five years old is that they're in there's 50,000 health professionals around 66 countries if you want extra reading to do about this and you like this topic medic review it's a really good paper and they collaborate with all kind of institutions and and things like that and people like say that you know people who go on the nettings trips also contribute to the medic review so it's a really a great source of news about medical system and Cuba and issues and I can also keep my card and I can send you some of the articles that medic shared with us if you're interested so I'll put my card on the table and I think thank you for having me if there any other I want to ask I know that some of the people that are seeking office in 2020 are advocating for free education to a certain level and others are advocating for a universal healthcare system I'd like to know what your facts are at that given your recent experience did it change your attitude that's great I love this question because something that I learned in Cuba was that the patient's like they were talking about a hundred percent vaccination rate and sort of the high level of use of the healthcare system and part of that is that it's free but part of that is the high literacy rate and the fact that most people have at least middle school of high school education so every almost everyone can read so so that being said that was a part of the utilization of the health system so I think now I'm starting to see that very linked so if we don't if we have one without the other like it might be impossible they give me a van a tional healthcare system but we still have people who don't know how to utilize it and the health literacy is less maybe it wouldn't work as well as it doesn't in Cuba so I think that's great because I'm starting to see how linked those two are after being in Cuba

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